In response to:

In his article “Health Care: The Disquieting Truth” [NYR, September 30], Arnold Relman states that “of all the providers of medical care, physicians are most important in determining how much will be spent” and that “in the US they account for only about 20 percent of medical expenditures.” He goes on to explain that physicians call on the facilities and services of all the other providers of care (hospitals, imaging centers, diagnostic labs, etc.), which is certainly the case. My experience with physicians is that they act as go-betweens. Recently, a physician referred me to three different testing centers for some internal discomfort that I was having. His bill was minimal but the testing center bills were high (with, by the way, negative results).

My question then is this: If physicians do in fact overuse medical services, why do they do it? I can readily think of two explanations: first, the physician has a financial interest in the testing center. A second explanation was not mentioned by Mr. Relman and involves the potential for lawsuits. My former doctor of many years repeatedly told me that doctors tend to overtreat out of fear of lawsuits. He said that doctors have to have an aggressive business strategy for dealing with potential medical malpractice situations. I know that the focus on medical malpractice as a cause of problems in our health system is seen by many as merely a partisan political issue, but it certainly seems relevant to me on the issue of changing the behavior of physicians in how they use medical resources.

Arthur Marquis
Long Beach, California

Arnold Relman replies:

Most physicians agree with Mr. Marquis that fear of lawsuits causes doctors to overuse medical services. However, no one really knows the actual extent to which the fear of lawsuits influences physician behavior, or how much it contributes to excessive medical expenditures. There are no objective and reliable methods to measure these effects directly.

Studies by the American Medical Association, the Congressional Budget Office, and health policy experts have produced widely varying monetary estimates of the cost, but I’m not aware of any study in which the estimate amounted to even 10 percent of total spending on medical care. Since per capita medical expenditures in the US exceed the average in most advanced countries by more than 100 percent, i.e., are more than twice the average of OECD countries, I do not think fear of lawsuits contributes very much to our excessive medical costs.

Furthermore, since there is no reason to believe that the influence of lawsuits, whatever it amounts to, is increasing each year, it is unlikely to explain the rapid rise of US costs. Nevertheless, I agree with those who say that the medical tort system is inequitable and ineffective, and should be reformed.

In other letters, readers said I did not emphasize two other important causes of excessive US health expenditures: the prevalence of health insurance and the failure of our medical education system to produce enough primary care physicians. The first of these, insurance coverage, cannot account for our uniquely high costs because many other countries with far more comprehensive insurance coverage have less expensive health care. In any case, reducing insurance coverage and expecting patients to pay directly for their own medical costs is unfair to those with limited means. It would be far better to control costs by changing the method of payment and the organization of the medical care system, as I have proposed.

I do recognize that primary physicians help to control costs, and I agree with those who say we have not done enough to make this an attractive career choice for medical graduates. In my article I argue that inadequate income and difficult work conditions are the basic reasons for the unpopularity of primary care and I suggest salaried group practice as a solution.